Day 2: Catching Fire

Hey all,

It’s great to be back at the Telluride experience!  My co-participants have been asking me if it is worth coming back for a second experience and so far it is just as great as my first time!  Not only is it good to get a refresher on a lot of QI/PS topics, but you can never have too many unique and educational conversations about patient safety, especially when others share their story for you to learn from.  So in this theme, I thought I would share my own, especially because it hits on a human factor that we do not usually discuss.

The short version of my story is that a chronic status epilepticus patient in the Neuro ICU was tube fed into his abdomen when a nurse deflated his PEG balloon and it dislodged from his stomach while I was the covering in-house provider overnight for the Neuro ICU.  It took the whole night and countless minutes where I had no idea what was wrong and even with calling for help from the attending was not helpful until the early morning when we we had imaging done.  When I heard of the error I was furious at the nurse.  Luckily, I did not let my emotions get the better of me and I did not yell, or for that matter even talk with that nurse at all… for a long time.

The human factor issue I am referring to in this example is that of my response to the person I perceived as doing harm or making an error against my patient.  I have heard from many participants that their initial reaction to the pt videos we have seen have been anger toward the providers who erred.  I think this reaction sometimes is only natural and what makes us human.  I tend to be… passionate, toward pt care and get somewhat upset when I see a lack of work ethic or professionalism that leads to pt harm or near misses.  The more I hear from leaders like Dave, the more I need to remember that although it is OK to have those initial reactions, you should always step back and hear the whole story and give that provider the benefit of the doubt and look for other ways to improve the system.  It actually turned out that the nurse was a travel nurse and she thought we had a PEG tube system that she was used to working with at a different hospital as they looked very similar.  So she was unaware that she did anything wrong.

The subject line of this post is two fold, one bad and one good connotation… 1. We have to be MINDFUL of our anger toward different PS stories we hear can sometimes “catch fire” and get the better of our actions and pre-judgement toward others.

2.  I see the same PS/QI interest or “fire” in the spirits of those who go through a conference like this that I have seen before.  I hope, like many alums before us, this fire continues to burn brightly and spread to others in your home institutions!


-Justin Martello